Mental Illness and Violence: The Real Truth

The staggering chaos and unimaginable loss of life heightens the nation’s attention once again. As the images begin saturating the airwaves, the picture of a mentally unstable man starts to take shape.

The story becomes a subject that we’ve heard before – violence and mental illness.

While we ask the question, “Why has this happened again?” it's important to know that the answer isn’t a simplistic one.

Though statistics have shown that mass shootings of late have been done by young men with a history of mental illness, it’s not the entire story. In fact, it’s dangerously reductive.

While evidenced based research shows us that many who commit violent acts DO indeed have mental illness, there is more to this diagnostic picture. The 4% of individuals who are violent have very serious problems dealing with strong emotional thoughts and feelings, struggle with drugs and/or alcohol abuse, experience environmental stressors, school/job difficulties, financial issues, and social disturbances.[1] The other 96% living with mental illness are not violent, nor are likely to be prone to violence.

It can be easy for media and the general public to be misinformed about violence and mental health[2]. There is a long history of stigma and ignorance surrounding mental illness. Even as research has grounded mental illness in science, data in news broadcasts, newspapers and internet reporting about mental illness are often misquoted, misused or factually reported wrong.[3]

What is known about mental illness and violence is that it’s strongly linked to emotional regulation, the ability to inhibit or appropriately deal with strong emotions[4]. When aggressive impulses are experienced, they move through the structures of our brain for processing. For those who don’t have regulation issues, these negative feelings find a healthy expression in the form of sarcasm, talking issues through, or going for a run, for example.

In individuals who have poor emotional regulation, these brain operations fail to mediate provocative feelings like frustration, anger or rage. As a result, these enormously powerful feelings are not filtered, examined or contained – and transform into violent behavior. Not everyone who has mental illness has emotional dysregulation. But it can certainly be said that those who commit violent acts have significant dsyregulation problems, in what is often clinically called “top down” control systems[5].

Emotional regulation difficulties are a combination of genetic predispositions and learned behaviors that occur over life. Those with dysregulation issues have a high sensitivity and vulnerability to emotional events, a significantly amplified emotional response to such events, and return very slowly back to a baseline from their reactive state[6]. Individuals with emotional dysregulation often experience chronic stress, rejection and victimization. These experiences refuel frustration and anger and cycles the person back into an emotional dysregulation state.[7]. This vicious circle loops endlessly, often leading to violent outcomes.

Better Detection

It’s clear that there is still so much more to do to detect those at risk for violent acts. To address this challenge, we need to:

Be better educated about mental illness.

Highlight scientific risk factors for violent behaviors for use in ways that the general public, law enforcement and health professionals understand.

Develop better diagnostic procedures to detect those at risk for violence.

Create a task force of mental health professionals to work alongside law enforcement to better manage welfare calls and other duty to warn issues.

Respond more thoroughly and persistently as a society to those who display emotional regulation difficulties.

And close loopholes to the access to lethal means.

References

[1] Elbogen, E. & Johnson, S. (2009). The intricate link between violence and mental disorder: Results from the National Epidemiologic Survey on alcohol and related conditions. Archives of General Psychiatry, 66(2):152-161.

THANK YOU, THANK YOU, THANK YOU for writing this. Every single time we have another violent tragedy and the media and politicians start talking about mental illness, I am torn between laughing and screaming. First, because implying that mental illness is somehow a major cause of violence is just untrue (i.e., there is no evidence to support the notion that targeting mental illness would effectively prevent violence). The rate of violent crime is not significantly higher among people with mental illness than those without. And it risks stigmatizing mental illness even further, possibly keeping people from seeking treatment when they would greatly benefit from it.

But even worse is that talking about mental illness is nothing more than a smokescreen that prevents us from getting to the real issues. Mental illness accounts for at MOST 3-5% of violent crime (http://www.nejm.org/doi/full/10.1056/NEJMp068229), so even with 100% accuracy targeting mental illness, 97% of violent crime would still take place. Basic logic tells us that the common denominator across these incidents is guns -- not mental illness, not video games, and not any of the other false flags that are thrown up to distract us from the real issue. We have a gun problem, and until we recognize that and develop smart solutions to restrict illegal gun trafficking, underground gun sales, gun show loopholes, online gun sales, etc., we are not going to see a noticeable decline in gun violence. And beyond that, we have seen the development of a toxic gun culture in recent years in which gun owners perceive any attempt to implement gun safety laws as a direct threat to their ability to own a gun. Now, we have a bunch of angry, defensive, gun-toting men walking around in public places and trying to intimidate groups like Moms Demand Action. That's a very dangerous situation, and it's setting us up for more violence (not to mention the "weapon's effect," which is an entirely different problem that is cropping up in places that allow guns to be carried in places like restaurants and bars). These are the issues that need attention, and only when we shift the conversation to these issues will we begin to develop effective solutions.
Having said that, I am all for improving the mental health system -- but it's misleading to do so under the guise of "preventing violence."

In truth, many people with and without mental illness are violent. And many with and without mental illness are not violent. It's the risk factors for aggression that help us determine who is dangerous. And some of those were discussed in my article.

When we talk about particular disorders, like Asperger's, Autism. Schizophrenia, Depression, it's not so easy to predict violence, because those who live with such disorders have very unique experiences. It's not an all or nothing thing. But when we look more closely, using the science and data that tells us characteristics and behaviors that lead to violence, we get a better picture.

The tipping point is when a mental disorder *is also linked* to some of the issues I touched upon in this article. Also, not discussed in this piece is the age of onset for psychosis - which many of these young men were in, which is another risk factor. Psychosis, brief or recurrent, is a significant factor that is often slippery to diagnose - especially when a person refuses treatment.

There's a lot of misunderstanding about the autism spectrum when it comes to violence - and while I don't want to be the bearer of difficult facts, the truth is that there are indeed studies that reflect aggression and violence within this disorder. Those who act out are in the minority of the population, but it does exist.

I've worked with teens with mood disorders who were aggressive. I've worked with young adults with autism spectrum disorders who were aggressive, and I've worked with kids and adults with anxiety and personality disorders who were aggressive. The point here is that we need to identify the RISK FACTORS for VIOLENCE and not lose ourselves in the disorders themselves. It does a disservice to those of us who live with mental illness. The majority of people with mental health issues never, ever go down this path of violence.

Big Pharma out of control + complicit Doctors/Psychs = the violence we see today. Mixtures of meds and/or stopping abruptly have been directly linked to violent episodes. Mental illness...while quite real...is more importantly a multi-billion dollar market to Big Pharma and the Politicians/Doctors they own. Wake up people!

Although our present understanding of why tornados occur is pretty good: the factors range from the very general (USA midwest, certain months of the year) to the specific (certain temperature differences between air masses colliding in a specific way), it is still impossible to predict exactly where and when FUTURE tornados will strike, how intense they will be and how much devastation they cause. But the warning systems we have developed, while not perfect, do give some protection. Even a little warning allows people to protect themselves, so that their lives are saved even if their property is destroyed.

In the same way, many agencies are now intensely studying the horror of the "human storm", aka the spree-murderer who attacks strangers in public places; the hope is that if we can begin to piece together ALL the factors that all these spree-murderers have in common, ranging from the extremely general to the very specific, we will be able to intervene sooner and perhaps reduce the number of these tragedies in the future.

This "Mother Jones" article:

http://www.motherjones.com/politics/2012/07/mass-shootings-map

attempts to study these various factors. I think they are on the right track in their efforts to gather the hard, unpleasant facts about spree-murderers and organize the information.

What seems clear at this point is that it takes MULTIPLE factors coming together in an "ideal" place, time, and condition, for the "perfect storm" to occur and a spree-murderer to form and erupt in violence.

The broadest, most general criteria:
There are millions of young men aged 16-30 in the USA who are highly intelligent, socially awkward, who enjoy playing violent computer games, have access to private transportation, who own or have access to guns and who are white, but do NOT engage in mass murder.

Within those general criteria, there is a sub-set of thousands of individuals who also have a mental illness/mental disorder (or combination of mental illnesses or developmental disorders) who do NOT engage in mass murder.

Within that sub-set, there is a much smaller sub-sub-set of individuals who have AT LEAST two or more serious mental illnesses that feature specific precipitating behaviors and traits: high impulsivity; emotional dysregulation; easily triggered into rage; a tendency to lash out with physical violence against the self or against others when feeling rejected, thwarted, emotionally injured or threatened; a lack of affective empathy combined with feelings of grandiosity or superiority; a feeling of entitlement and justification to enact revenge fantasies against others in real life; breaks with reality, chiefly. Note: Asperger's individuals are not prone to violence, but they are prone to having difficulty fitting in, making friends, and having a more or less satisfying, normal social life. Asperger's kids tend to get bullied, and being chronically rejected by peers of both sexes and chronically bullied will OF COURSE generate hurt, resentment, emotional pain, and possibly feelings of wanting revenge.

Out of that very small number of individuals (with multiple mental illnesses/developmental disorders) there is an even smaller sub-sub-sub set of individuals impacted by highly specific factors that begin to have greater importance, such as:

*the individual's mental illnesses are either not being treated at all, or they are being treated improperly (incorrect diagnosis, prescription meds are not effective, or not taken at all, or withdrawn suddenly, or are taken in combination with alcohol/other drugs, etc.)

*the individual's functionality is deteriorating: he becomes increasingly and more openly hostile, violent and disturbing to those who are closest to him (room-mates, co-workers, relatives, teachers, etc.)

AND

*the individual has the personal freedom to come and go as he pleases; he is an out-patient despite the fact that he is so unstable and volatile that he SHOULD BE an in-patient living under 24/7 professionally-supervised medical /psychiatric care (in a psychiatric hospital.)

...that last factor is the equivalent of the air masses colliding and the rotation of winds beginning. That's when all the general-to-specific factors coalesce into the "perfect storm" that causes death and destruction to innocent people.

That's my take on these situations, anyway. Spree-murder is the result of MULTIPLE factors ranging from the general to the very specific. We need to better understand these factors and develop better methodologies and practices and services to interrupt the likelihood that these factors will coalesce to the point of no return, and hopefully avoid or reduce the number of "perfect storms" of human destruction in the future.

Yes, there are many causal factors, many of which are difficult to prove. While we can gather information and see the similarities between and among people who murder, we must remain open to all possibilities and not lean just on one. It's simply too reductive.

Thanks for sharing, and the Mother Jones article is sadly one I've been turning to time and again as they ad another mass shooting.